Preauthorization medication or prior authorization is a process that involves the receipt of agreement by a payer for the provision of the services before they are provided. In the profession of medical billing it is very important to deal with the preauthorization process as a part of the job. Usually the payer of the services authorizes for it before the services are actually provided and assigns a unique authorization number that is included as a specification on the claim during payment submissions.
The correct and proper way of accurate preauthorization is to provide a CPT code or Correct Procedural Code. The tough task is to determine and identify the CPT code prior to the service provision with authentic documentation.
It is necessary to evaluate and provide the correct code. In the preauthorization medication, one should contact and coordinate with the physician about what kind of treatment he or she would carry along with all the possible scenarios. One might get into trouble if the procedure performed was not covered.
The medication and treatment must be authorized beforehand because if payment is denied for no authorization, it would incur penalty. When a procedure is unauthorized and not mentioned, a person can claim no authorization for unrendered treatment.
In situations of emergency when the patient or his family is not present, the coverage is unavailable due to uncertainty. An accident or sudden illness can be the cases of such emergency. In such cases the medication service provider has to contact the patient as soon as possible and complete the authorization agreement process.
In the context of healthcare and healthcare insurance, there is an important mention of the precertification services medical billing. The process pre-approves the specific medical procedures that would be carried out or prescribed medicines that would be given during the treatment. It is important that the patients meet some requirements before they extend any form of coverage for medication services. The doctors are supposed to provide proper documentation of the patient’s illness and methods of treatment involved. The precertification services are also provided by hospitals to insurance companies about the inpatient admissions.
The process of precertification and preauthorization limits the cost spent on treatment enormously and the hospitals charge for only the medications that they have provided to the patient. It helps in the cost containment. However, these two processes are different in nature.
Pre authorization deals with the determination of appropriateness and the total cost incurred of a check-up, treatment or medication. The process reviews, in detail, the medical history of patients, the type of treatment and the prescribed drugs.
Whereas, pre certification deals with the requisites to gain permission to perform a specific kind of treatment whem a patient is admitted in the hospital by the payer. It also covers the procedural list provoded by the payer earlier. It also determines the eligibility of a patient with his health insurer.
The development of automated softwares have simplified the sea of paperwork and to keep a record of patients, their treatment and their bills.